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' Z909 IN Ad E tiI0 'S[ 'ApA awil paniaaad/ <br /> CITY OF MANT'ECA WOC� <br /> WASTE MAULER'S SOURCE CERTIFICATION <br /> 1. PR UCER OF LIOM WASTE pH <br /> NAMEt � rL PHorr&o ) f��� <br /> PICK-UPADSs_ I�U a S, �cAtjaw � Z��o P ca, �5 3n <br /> Number Street City State Zip <br /> WASTE SOURCE: DO JEJST C WASTEWATER ONLY from(circle one): epae T Portable Toilet <br /> PICK-UP DATE / / TIME_3,'3�3 QUANTITY :�5toq, meals <br /> I certify that this waste was delivered to the hauler named below for legal disposal at the site indicated- <br /> Printed Name of Owner,Occupant or Agent Signature ofer, ccnpa or Agent <br /> • <br /> 2- HAULER <br /> NAIL Roto Rooter n <br /> BUSINESS ADDRESS o�� /Ueu��U�L V�� g+ '' k4�1 C � <br /> Number Street city State Zip <br /> I certify that the described waste was hauled Jby me to the disposal facility.named below. °� <br /> Receiving Station Permit No. 9�,~/ Vehicle License /No- 7,3052— <br /> Printed Name of Hauler Signature of Hauler <br /> 3. RECEIVING STATION <br /> NAME AND ADDRESS: City of Manteca WQCF 2450 West Yosemite Ave- Manteca,CA 95337 <br /> I certify that the hauler above delivered the desenbed liquid waste to this disposal facility,and that it was <br /> accepted/rejected(circle one)material under the terms of the Receiving Station Permit. <br /> SignatarePof Waste Facility Operator <br /> DATE A-`1-k4 TIME IN 3`47 TIME OUT NET QUANTITY �3, gals <br /> Rev.02/013 ogee assistantlforms <br /> 50/V0 d3io0a 010a 9Z6559V60z VZ:VT VTK/5T/50 <br />